Sputum Acid-fast Bacilli Smear Research Articles

The characteristics of patients with pulmonary Mycobacterium avium-intracellulare complex disease diagnosed by bronchial lavage culture compared to those diagnosed by sputum culture.

The utility of bronchoscopy for the diagnosis of pulmonary Mycobacterium avium-intracellulare complex (MAC) disease has been reported; however, which patients require bronchoscopy remains unclear. Our objective was to identify the characteristics of the patients in whom bronchoscopy is needed for the diagnosis of MAC disease. Fifty-four patients with pulmonary MAC disease were divided into two groups according to established diagnostic criteria: 39 patients were diagnosed by sputum culture and 15 patients were diagnosed by bronchial lavage culture. We analysed the differences in demographic and clinical characteristics as well as microbiological and radiological data between the two groups. There were no significant differences in age, sex, smoking status, MAC species, underlying diseases, or steroid use. Significantly more patients diagnosed by sputum culture than bronchial lavage culture had a positive sputum smear for acid-fast bacilli (79.5% vs. 0.0%, respectively; p<0.001) and any symptoms (75.3% vs. 46.2%, respectively; p=0.0059). No significant differences were found in the prevalence of each computed tomography finding, including nodules, air-space disease, bronchiectasis, and cavities. However, more patients diagnosed by sputum culture than bronchial lavage culture had abnormalities in the left upper division (48.7% vs. 13.3%, respectively; p=0.017) and higher numbers of affected lobes (4.3±1.4 vs. 3.3±1.6, respectively; p=0.034). If patients suspected of having pulmonary MAC disease have a negative sputum smear, no symptoms, no abnormal findings in the left upper division, or fewer affected lobes on computed tomography, bronchoscopy might be needed for the diagnosis.

Liquid culture enhances diagnosis of patients with milder forms of non-tuberculous mycobacterial lung disease

To evaluate the proportion and clinical characteristics of patients with non-tuberculous mycobacteria (NTM) lung disease diagnosed based on positive culture results in liquid medium only. We reviewed the medical records of 978 patients diagnosed with NTM lung disease. All clinical samples were cultured in both solid and liquid media. Of the 978 patients, 111 (11.3%) were culture-positive in liquid medium only (liquid culture group), and 867 (88.7%) (solid culture group) on solid medium, regardless of the culture results in liquid medium. At the time of diagnosis, the liquid culture group was less likely than the solid culture group to have haemoptysis (11.7% vs. 20.0%, P = 0.04), positive sputum smear for acid-fast bacilli (14.4% vs. 50.2%, P < 0.001) or the fibrocavitary form of NTM lung disease (3.6% vs. 14.6%, P = 0.001). During the median follow-up period of 28.9 months (interquartile range 19.1-41.6), the proportion of patients requiring antibiotic treatment was lower in the liquid culture group than in the solid culture group (44.1% vs. 61.6%, P < 0.001). Liquid media culture is helpful in the diagnosis of patients with less severe forms of NTM lung disease.

Natural history of Mycobacterium avium complex lung disease in untreated patients with stable course.

Little is known about the long-term natural history of Mycobacterium avium complex lung disease (MAC-LD) in untreated patients with stable course.The aim of this study was to investigate the natural course of untreated stable MAC-LD, with a focus on factors associated with clinical deterioration, spontaneous sputum conversion and prognosis.Of 488 patients diagnosed with MAC-LD between 1998 and 2011, 305 patients (62.5%) showed progressive MAC-LD resulting in treatment initiation within 3 years of diagnosis and 115 patients (23.6%) exhibited stable MAC-LD for at least 3 years with a median follow-up duration of 5.6 years. Patients with stable MAC-LD were more likely to have higher body mass index and less systemic symptoms at initial diagnosis compared with patients with progressive MAC-LD, while positive sputum acid-fast bacilli smear, fibrocavitary type and more extensive disease in radiological findings were more associated with progressive MAC-LD. Of the untreated patients with stable MAC-LD, 51.6% underwent spontaneous sputum conversion, with younger age, higher body mass index and negative sputum acid-fast bacilli smear at initial diagnosis found to be predictors of this occurrence.Advanced age, fibrocavitary type and abnormal pulmonary function were negative prognostic factors for survival in patients with stable MAC-LD.

Factors associated with sputum culture conversion in patients with pulmonary tuberculosis

ObjectiveThe aim of this study was to determine what factors are associated with sputum culture conversion after 1 month of tuberculosis (TB) treatment. Materials and methodsA total of 52 patients with new drug susceptible pulmonary TB were included in the study. Patients completed St. George respiratory questionnaire (SGRQ), they were asked about smoking, alcohol use, living conditions and education. Body mass index (BMI) measurements, laboratory tests (C reactive protein [CRP], vitamin D, albumin) were performed, and chest X-ray was done. After 1 month of treatment sputum culture was repeated. ResultsCulture conversion after 1 month of treatment was found in 38.5% cases. None of investigated social factors appeared to have an effect on conversion, but worse overall health status (as reported in SGRQ) and longer duration of tobacco smoking were detected in the “no conversion” group. Concentrations of albumin, CRP, X-ray score and the time it took Mycobacterium tuberculosis culture to grow also differed. Patients who scored 30 or more on SGRQ were more than 7 times as likely to have no conversion. However, the most important factor predicting sputum culture conversion was sputum smear grade at the beginning of treatment: patients with grade of 2+ or more had more than 20-fold higher relative risk for no conversion. Using receiver operating characteristic curve analysis, we also developed a risk score for no conversion. ConclusionsThe most important factors in predicting sputum culture conversion after 1 month of treatment were grades of acid-fast bacilli in sputum smears at time of diagnosis and scores of SGRQ.

Levamisole as an Adjuvant to Short-Course Therapy in Newly Diagnosed Pulmonary Tuberculosis Patients.

Background:The estimated incidence and prevalence of tuberculosis in India are 2.1 and 2.6 million cases respectively. Immunotherapy may shorten tuberculosis treatments and improve the immunity of individuals as well. Hence we study the efficacy of levamisole (LVM) (immunomodulator) as an adjuvant to chemotherapy of pulmonary tuberculosis patients.Materials and Methods:A randomized, double-blind, placebo-controlled clinical trial was conducted for 21 months in newly diagnosed sputum positive pulmonary tuberculosis patients. Patients were subjected initially to clinical examination, sputum acid-fast bacilli smear and culture, tuberculin skin test and weight record. During follow-up, above investigations were repeated. Sixty-five patients were randomly assigned into two groups to receive either tab LVM 100 mg once in a day or matching placebo, orally as a single dose, thrice a week, for 2 months with short-course antituberculosis chemotherapy.Results:Sputum negativity at 1 week was observed in 11 (44%) patients in LVM group whereas only 3 (12%) in placebo group. All the patients 25 (100%) in LVM group were sputum negative compared to 14 (56%) in placebo group by the end of 3 weeks. In LVM group, 24 (96%) and 11 (44%) patients in placebo group show radiological improvement at 2 months. A direct correlation existed between quantum of immune response and weight gain with LVM. LVM rendered all anergic patients to positive tuberculin reactors. In LVM group, patients with initial Mantoux ≥20 mm and advanced cavitary disease, there was decrease in tuberculin reaction size.Conclusion:Adjuvant immunomodulation with levamisole has the potential of shortening the total duration of antitubercular therapy.

Colonic tuberculosis

A 22-year-old previously healthy Ethiopian woman was admitted with a history of colicky lower-abdominal pain associated with vomiting, diarrhea, fever, night sweats, and unintentional weight loss. CT showed mildly dilated proximal small-bowel loops with air fluid levels, with mesenteric lymphadenopathy and congestion, associated with right iliac fossa fat stranding and bowel wall enhancement. Colonoscopy demonstrated multiple submucosal lesions extending from the splenic flexure to the ascending colon (A and B). The lesions extruded white chylous fluid during biopsy (C and D), which suggested a cystic nature. Multiple biopsy specimens were taken from the cyst wall, and the cyst content was sent for culture and cytology. Histopathologic examination revealed submucosal fibrosis with foci of inflammatory cells and ill-defined granulomas on deeper levels; Ziehl-Neelsen staining showed acid-fast bacilli (AFB). A sputum smear for AFB was negative; however, culture from the cyst aspirate was positive for Mycobacterium tuberculosis. Cytology was unremarkable.

Operating Characteristics of a Tuberculosis Screening Tool for People Living with HIV in Out-Patient HIV Care and Treatment Services, Rwanda

BackgroundThe World Health Organization (WHO) 2010 guidelines for intensified tuberculosis (TB) case finding (ICF) among people living with HIV (PLHIV) includes a recommendation that PLHIV receive routine TB screening. Since 2005, the Rwandan Ministry of Health has been using a five-question screening tool. Our study objective was to assess the operating characteristics of the tool designed to identify PLHIV with presumptive TB as measured against a composite reference standard, including bacteriologically confirmed TB.MethodsIn a cross-sectional study, the TB screening tool was routinely administered at enrolment in outpatient HIV care and treatment services at seven public health facilities. From March to September 2011, study enrollees were examined for TB disease irrespective of TB screening outcome. The examination consisted of a chest radiograph (CXR), three sputum smears (SS), sputum culture (SC) and polymerase chain reaction line-probe assay (Hain test). PLHIV were classified as having “laboratory-confirmed TB” with positive results on SS for acid-fast bacilli, SC on Lowenstein-Jensen medium, or a Hain test.ResultsOverall, 1,767 patients were enrolled and screened of which; 1,017 (57.6%) were female, median age was 33 (IQR, 27–41), and median CD4+ cell count was 385 (IQR, 229–563) cells/mm3. Of the patients screened, 138 (7.8%) were diagnosed with TB of which; 125 (90.5%) were laboratory-confirmed pulmonary TB. Of 404 (22.9%) patients who screened positive and 1,363 (77.1%) who screened negative, 79 (19.5%) and 59 (4.3%), respectively, were diagnosed with TB. For laboratory-confirmed TB, the tool had a sensitivity of 54.4% (95% CI 45.3–63.3), specificity of 79.5% (95% CI 77.5–81.5), PPV of 16.8% and NPV of 95.8%.ConclusionTB prevalence among PLHIV newly enrolling into HIV care and treatment was 65 times greater than the overall population prevalence. However, the performance of the tool was poorer than the predicted performance of the WHO recommended TB screening questions.

Diagnostic utility of serum adenosine deaminase level in the diagnosis of pulmonary tuberculosis

This study was conducted to evaluate the role of serum adenosine deaminase (ADA) level in the diagnosis of pulmonary tuberculosis (TB) and its relationship with clinical, radiological, and laboratory parameters. This study was performed on 70 individuals: 60 patients with tuberculous and nontuberculous pulmonary diseases and 10 apparently healthy individuals as a control group. The participants were divided into four groups: group I included 30 patients with active pulmonary TB who were subdivided into group IA, which included 20 patients with sputum smear-positive pulmonary TB, and group IB, which included 10 patients with sputum smear-negative pulmonary TB (culture positive); group II included 10 patients with tuberculous pleural effusion; group III included 20 patients with nontuberculous lung diseases (five cases with pneumonia, five cases with pyogenic lung abscess, five cases with bronchiectasis, three cases with lung cancer, and two cases with mesothelioma); and group IV included 10 apparently healthy individuals as a control group. Patients were subjected to history taking, clinical examination, plain chest radiography posterior–anterior view, three consecutive sputum smears for acid-fast bacilli (AFB), sputum culture for AFB using BACTEC TB-460 system in group IB, laboratory investigations, tuberculin skin test, serum ADA level evaluation in all participants, and pleural ADA level evaluation in cases of tuberculous pleural effusion. Serum ADA showed high percentage positivity (90%) in the diagnosis of pulmonary TB, followed by tuberculin skin test (83.3%), chest radiography (73.3%), erythrocyte sedimentation rate (70%), sputum for AFB (66.6%), toxic symptoms (53.3%), and hemoptysis (36.3%). Serum ADA sensitivity and specificity at cut-off point 30.15 μ/l were 95 and 86.7%, respectively, with a positive predictive value of 90.5%, negative predictive value of 92.2%, and accuracy of 91.4%. Serum ADA level shows higher percentage positivity compared with clinical, radiological, and laboratory parameters in the diagnosis of pulmonary TB.

Cough Aerosols of Mycobacterium tuberculosis in the Prediction of Incident Tuberculosis Disease in Household Contacts.

Tuberculosis disease develops in only 5%-10% of humans infected with Mycobacterium tuberculosis The mechanisms underlying this variability remain poorly understood. We recently demonstrated that colony-forming units of M. tuberculosis in cough-generated aerosols are a better predictor of infection than the standard sputum acid-fast bacilli smear. We hypothesized that cough aerosol cultures may also predict progression to tuberculosis disease in contacts. We conducted a retrospective cohort study of 85 patients with smear-positive tuberculosis and their 369 household contacts in Kampala, Uganda. Index case patients underwent a standard evaluation, and we cultured M. tuberculosis from cough aerosols. Contacts underwent a standard evaluation at enrollment, and they were later traced to determine their tuberculosis status. During a median follow-up of 3.9 years, 8 (2%) of the contacts developed tuberculosis disease. In unadjusted and adjusted analyses, incident tuberculosis disease in contacts was associated with sputum Mycobacterial Growth Indicator Tube culture (odds ratio, 8.2; 95% confidence interval, 1.1-59.2; P = .04), exposure to a high-aerosol tuberculosis case patient (6.0, 1.4-25.2; P = .01), and marginally, human immunodeficiency virus in the contact (6.11; 0.89-41.7; P = .07). We present data demonstrating that sputum and aerosol specimens measure 2 related but different phenomena. We found an increased risk of tuberculosis progression among contacts of high-aerosol case patients. The hypothesis that a larger infectious inoculum, represented by high aerosol production, determines the risk of disease progression deserves evaluation in future prospective studies.

Decentralization of Acid Fast Bacilli(AFB) External Quality Assurance Using Blind Rechecking for Sputum Smear Microscopy in Ethiopia

IntroductionEthiopia achieved a rapid expansion of TB microscopic centers for acid fast bacilli (AFB). However, external quality assurance (EQA) services were, until recently, limited to few regional and sub-regional laboratories. In this paper, we describe the decentralization experience and the result of EQA using random blinded rechecking.Materials and MethodsThe routine EQA quarterly report was compiled and analyzed. A positive result by the microscopic center while the EQA center reported negative result is categorized as false positive (FP). A negative result by the microscopic center while the EQA center reported positive is considered false negative (FN). The reading of EQA centers was considered a gold standard to compute the sensitivity, specificity, positive predictive (PPV) and negative predictive values (NPV) of the readings of microscopic centers.ResultsWe decentralized sputum smear AFB EQA from 4 Regional Laboratories (RRLs) to 82 EQA centers and enrolled 956 health facilities in EQA schemes. Enrollment of HFs in EQA was gradual because it required training and mentoring laboratory professionals, institutionalizing internal QA measures, equipping all HFs to perform diagnosis, and establishing more EQA centers. From 2012 to 2014 (Phase I), the FP rate declined from 0.6% to 0.2% and FN fell from as high as 7.6% to 1.6% in supported health facilities (HFs). In HFs that joined in Phase II, FN rates ranged from 5.6 to 7.3%. The proportion of HFs without errors has increased from 77.9% to 90.5% in Phase I HFs and from 82.9% to 86.9% in Phase II HFs. Overall sensitivity and specificity were 95.0% and 99.7%, respectively. PPV and NPV were 93.3% and 99.7%, respectively.ConclusionDecentralizing blinded rechecking of sputum smear microscopy is feasible in low-income settings. While a comprehensive laboratory improvement strategy enhanced the quality of microscopy, laboratory professionals’ capacity in slide reading and smear quality requires continued support.

High Rates of Tuberculosis and Opportunities for Prevention among International Students in the United States.

Foreign-born persons traveling on a student visa are not currently screened for tuberculosis on entry into the United States, despite residing in the United States for up to several years. To characterize the risk of tuberculosis in international students entering the United States and to identify strategies for early diagnosis and prevention in this population. Data were collected in 18 tuberculosis control jurisdictions in the United States. A cohort of 1,268 foreign-born patients of known visa status, diagnosed with active tuberculosis between 2004 and 2007, was used for analysis. Incidence rates were estimated on the basis of immigration data from study jurisdictions. Tuberculosis was diagnosed in 46 student residents, providing an annual estimate of 308 cases nationally. The estimated tuberculosis case rate in student residents was 48.1 cases per 100,000 person-years (95% confidence interval, 35.6-64.8), more than twice that of the general foreign-born population. Students identified by tuberculosis screening programs were more likely to be diagnosed within 6 months of U.S. arrival (75 vs. 6%; P < 0.001), and those with pulmonary disease were less likely to have a positive sputum smear for acid-fast bacilli compared with those not screened (18 vs. 63%; P = 0.05). In unscreened students, 71% were diagnosed more than 1 year after U.S. arrival and only 6% were previously treated for latent tuberculosis infection. The tuberculosis case rate in foreign-born students is significantly higher than in other foreign-born individuals. Screening this group after arrival to the United States is an effective strategy for earlier diagnosis of active tuberculosis.

A rare case of systemic sarcoidosis with cutaneous and sublingual salivary gland involvement

Sarcoidosis is a systemic granulomatous disorder of unidentified etiology and pathologically character­ized by non-caseating granulomas. Majority of patients (~30%) have cutaneous lesions, exhibit different manifestations depending on diverse races whereas some patients develop systemic involvement. Diagnosis is based on a compatible clinical and radiological presentation and evidence of non-caseating granulomas. Here, we report a rare case of cutaneous sarcoidosis with a nodulocystic swelling on the floor of the mouth, which upon biopsy revealed a dense, non-caseating granulomatous infiltrate in the dermis. Identification of systemic involvement was based on laboratory investigations, slit skin smear, sputum smear for acid-fast bacilli (AFB), chest X-ray, pulmonary function tests, computerized tomography (CT), ultrasound of abdomen and radiological examination. The patient was treated successfully and is being reviewed once every two weeks till date. Keywords: Cutaneous, Granuloma, Papules, Sarcoidosis, Systemic

Impact of CD4 Count on sputum smear for AFB in HIV-TB Co infection

Background: Human immunodeficiency virus (HIV) infection is a major threat in the world population and in the control of tuberculosis in developing countries. HIV-TB co infected patients with CD4 counts above 200 cells/cu µl, are likely to have typical symptoms and most of the sputum shows positive for acid fast bacilli (AFB). Patient withCD4 count less than 200 are with high risk of getting (Tuberculosis) TB, but diagnosis is difficult as there is more chances of sputum becoming negative, which requires sputum culture for diagnosis of (TB). Although sputum smear negativity is high in most cases of dual infection, particularly in patients with low immunity, it is an essential component in the diagnosis of tuberculosis in countries like India. Methodology: A cross sectional study of 50 HIV-TB patients admitted to tertiary care hospital were studied for correlation between CD4 count and sputum smear results. Results: 50 HIV-TB patients studied for a period of 1 year. Majority were in the age group of 30-40 years 20 (78%). In the study 29 (58%) were males and 21(42%) were females. The common presentations were cough 48 (96%), fever 44 (88%), weight loss 42(84%) and diarrhoea 25(50%). Mean CD4 count being 146.6±88. Most patients had CD4 count < 200 cells/cu µl. Mean CD4 count in sputum positive TB was 254.8±77.3 and in sputum negative TB was 97.2±33.8. Conclusion: Patients with CD4 count > 200cells/cuµl are likely to have sputum positive pulmonary TB and typical presentations. Patients with CD4count < 200cells/cuµl are more of sputum negative pulmonary TB with atypical presentations which poses diagnostic difficulty and needs newer diagnostic tests. Key words: HIV-TB co infected patients, CD4 count, Sputum for AFB

Comparative study of clinico-bacterio-radiological profile and treatment outcome of smokers and nonsmokers suffering from pulmonary tuberculosis.

Introduction:Tuberculosis (TB) is one of the leading causes of death and disease worldwide. Tobacco smoking has been linked as a risk factor for TB. This study was aimed to affirm the strength of association between smoking and pulmonary TB.Materials and Methods:Pulmonary TB patients aged between 18 and 65 years were enrolled and followed-up until treatment completion. Two consecutive sputum smears were examined from each patient for the presence of acid-fast bacilli (AFB) using Ziehl–Neelsen technique. Radiological severity of disease was assessed using guidelines of National TB Association of USA. Sputum smears for AFB were graded for positivity as per WHO Revised National TB Control Programme criteria. Response was determined in terms of sputum conversion at the end of intensive phase and final treatment outcomes.Results:Sputum smear grading of 3+ increased from 12.5% to 68.18% and 66.66% as smoking index increased from <100 to 100–299 and >300 (P < 0.05). In nonsmokers, 79.2% patients had minimal disease while only 4.2% had advanced disease as compared to smokers where 52.4% had moderate disease, 26.2% advanced disease, and 21.4% minimal disease (P < 0.01). Smokers had significantly lower treatment success rate (69%) as against nonsmokers and former smokers (93.8% and 90.9%, respectively, P = 0.001) owing to a higher default rate among smokers (28.5%) than nonsmokers (6.3%) and former smokers (9.1%).Conclusion:Smokers during initial presentation, as well as at end of the treatment demonstrate more radiological findings, cavitary disease, and worse sputum AFB smear grading. Smokers also have a poorer treatment success rate largely due to high percentage of default rate thus suggesting noncompliance as a main confounder to treatment success. Focus needs to be made to reduce defaulters which are more common among smokers.

Clinical Correlates and Drug Resistance in HIV-Infected and -Uninfected Pulmonary Tuberculosis Patients in South India.

ObjectivesTo examine demographics, clinical correlates, sputum AFB (acid fast bacilli) smear grading DOTS (Directly Observed Therapy Short Course) uptake, and drug resistance in a cohort of newly-diagnosed, smear positive pulmonary tuberculosis (TB) patients with respect to HIV status at baseline, and compare smear conversion rates, side effects and mortality after two months.DesignA prospective study among 54 HIV positive and 41 HIV negative pulmonary TB patients. Data were collected via face-to-face interviews, review of medical records, and lab tests.ResultsHIVTB co-infected patients, though more symptomatic at baseline, showed more improvement in their symptoms compared to HIV-uninfected TB patients at follow-up. The HIV co-infected group had more prevalent perceived side effects, and sputum smear positivity was marginally higher compared to the HIV negative group at follow-up. Mortality was higher among the HIV-infected group. Both groups had high rates of resistance to first-line anti-tubercular drugs, particularly isoniazid. There was no significant difference in the drug resistance patterns between the groups.ConclusionsPrompt initiation and provision of daily regimens of ATT (Anti-Tubercular treatment) along with ART (Anti-Retroviral treatment) via ART centers is urgently needed in India. As resistance to ART and/or ATT is directly linked to medication non-adherence, the use of counseling, regular reinforcement, early detection and appropriate intervention strategies to tackle this complex issue could help prevent premature mortality and development of resistance in HIV-TB co-infected patients. The high rate of isoniazid resistance might preclude its use in India as prophylaxis for latent TB in HIV infected persons as per the World Health Organization (WHO) guideline.

Impact of HIV on mortality among patients treated for tuberculosis in Lima, Peru: a prospective cohort study.

BackgroundHuman immunodeficiency virus (HIV)-associated tuberculosis deaths have decreased worldwide over the past decade. We sought to evaluate the effect of HIV status on tuberculosis mortality among patients undergoing treatment for tuberculosis in Lima, Peru, a low HIV prevalence setting.MethodsWe conducted a prospective cohort study of patients treated for tuberculosis between 2005 and 2008 in two adjacent health regions in Lima, Peru (Lima Ciudad and Lima Este). We constructed a multivariate Cox proportional hazards model to evaluate the effect of HIV status on mortality during tuberculosis treatment.ResultsOf 1701 participants treated for tuberculosis, 136 (8.0 %) died during tuberculosis treatment. HIV-positive patients constituted 11.0 % of the cohort and contributed to 34.6 % of all deaths. HIV-positive patients were significantly more likely to die (25.1 vs. 5.9 %, P < 0.001) and less likely to be cured (28.3 vs. 39.4 %, P = 0.003). On multivariate analysis, positive HIV status (hazard ratio [HR] = 6.06; 95 % confidence interval [CI], 3.96–9.27), unemployment (HR = 2.24; 95 % CI, 1.55–3.25), and sputum acid-fast bacilli smear positivity (HR = 1.91; 95 % CI, 1.10–3.31) were significantly associated with a higher hazard of death.ConclusionsWe demonstrate that positive HIV status was a strong predictor of mortality among patients treated for tuberculosis in the early years after Peru started providing free antiretroviral therapy. As HIV diagnosis and antiretroviral therapy provision are more widely implemented for tuberculosis patients in Peru, future operational research should document the changing profile of HIV-associated tuberculosis mortality.

Rifampin resistance and diabetes mellitus in a cross-sectional study of adult patients in rural South India.

BackgroundDespite increasing reports of the linkage between diabetes and tuberculosis (TB), there is limited information regarding diabetes and TB drug resistance.MethodsIn this cross-sectional study, sputum and blood samples were collected from 304 adult patients in rural Andhra Pradesh. Rifampin resistance was assessed by Xpert MTB/RIF (Xpert), and diabetes status was based on self-report. Additionally, samples were assayed by acid-fast bacilli sputum smear microscopy (AFB) and QuantiFERON-TB Gold In-Tube (QFT-G), in order to compare relative diagnostic performances.ResultsAmong patients with confirmed TB (n = 194), diabetes was associated with 3.0-fold higher risk of rifampin resistance (95 % CI 1.3–6.7). Considering Xpert MTB/RIF the gold standard, AFB had lower sensitivity (72.2 vs. 82.5 %) and higher specificity (96.4 vs. 37.0 %) compared to QFT-G for diagnosing TB.ConclusionsThe increased risk of rifampin resistance in patients with diabetes highlights the need for integrated diabetes surveillance in TB programs, particularly in settings undergoing the epidemiological transition.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-015-1204-5) contains supplementary material, which is available to authorized users.

Risk Factors for Multidrug-Resistant Tuberculosis among Patients with Pulmonary Tuberculosis at the Central Chest Institute of Thailand.

There are limited data available on the risk factors for multidrug-resistant tuberculosis (MDR-TB). Therefore, we here conducted a retrospective matched case−control study among adults with pulmonary TB who received treatment at the Central Chest Institute of Thailand (CCIT) between January 2007 and December 2013, in order to determine the risk factors associated with MDR-TB among patients with pulmonary TB. We identified 145 patients with pulmonary MDR-TB (cases) and 145 patients with drug-sensitive pulmonary TB (controls). Multivariate analysis identified the independent risk factors for MDR-TB as follows: (1) ≥ 2 episodes of prior pulmonary TB (odds ratio [OR] 39.72, 95% confidence interval (95% CI) 7.86−200.66), (2) duration of illness > 60 days (OR 3.08, 95% CI 1.52−6.22), (3) sputum acid fast bacilli smear 3+ (OR 13.09, 95% CI 4.64−36.91), (4) presence of lung cavities (OR 3.82, 95% CI 1.89−7.73), and (5) presence of pleural effusion (OR 2.75, 95% CI 1.06−7.16). Prior pulmonary TB management with a non-category I regimen (P = 0.012) and having treatment failure or default as treatment outcomes (P = 0.036) were observed in a higher proportion among patients with MDR-TB. Particular characteristics of lung cavities, including the maximum diameter ≥ 30 mm (P < 0.001), the number of cavities ≥ 3 (P = 0.001), bilateral involvement (P < 0.001), and ≥ 2 lung zones involved (P = 0.001) were more commonly observed in patients with MDR-TB. In conclusion, these clinical factors and chest radiographic findings associated with MDR-TB among patients with pulmonary TB may help physicians to provide proper management of cases for prevention of the development and spread of MDR-TB in future.

Review of nucleic acid amplification tests and clinical prediction rules for diagnosis of tuberculosis in acute care facilities.

Tuberculosis (TB) remains an important cause of hospitalization and mortality in the United States. Prevention of TB transmission in acute care facilities relies on prompt identification and implementation of airborne isolation, rapid diagnosis, and treatment of presumptive pulmonary TB patients. In areas with low TB burden, this strategy may result in inefficient utilization of airborne infection isolation rooms (AIIRs). We reviewed TB epidemiology and diagnostic approaches to inform optimal TB detection in low-burden settings. Published clinical prediction rules for individual studies have a sensitivity ranging from 81% to 100% and specificity ranging from 14% to 63% for detection of culture-positive pulmonary TB patients admitted to acute care facilities. Nucleic acid amplification tests (NAATs) have a specificity of >98%, and the sensitivity of NAATs varies by acid-fast bacilli sputum smear status (positive smear, ≥95%; negative smear, 50%-70%). We propose an infection prevention strategy using a clinical prediction rule to identify patients who warrant diagnostic evaluation for TB in an AIIR with an NAAT. Future studies are needed to evaluate whether use of clinical prediction rules and NAATs results in optimized utilization of AIIRs and improved detection and treatment of presumptive pulmonary TB patients.

Trends in Tuberculosis Cases Among Nursing Home Residents, California, 2000 to 2009.

To examine trends in tuberculosis (TB) incidence and to compare demographic and clinical characteristics of nursing home (NH) residents and community-dwelling older adults. Prospective TB surveillance. TB cases reported in California from 2000 to 2009. TB patients aged 65 and older. Trends in TB incidence per 100,000 population were assessed using Poisson regression. Demographic and clinical characteristics were compared using the chi-square or Wilcoxon rank-sum test. Among NH residents, risk factors for death during TB treatment were identified using logistic regression. From 2000 to 2009, TB incidence rates decreased significantly, from 15.9/100,000 to 8.4/100,000 (-44%, 95% confidence interval (CI)=-66% to -7%) for NH residents and from 21.2/100,000 to 15.0/100,000 (-27%, 95% CI=-29% to -24%) for community-dwelling older adults. Overall, 211 TB cases among NH residents and 6,518 cases among community-dwelling older adults were reported. NH residents were more likely than community-dwelling older adults to be older (median age 81 vs 75, P<.001), have a negative acid-fast bacilli sputum smear and positive culture (37% vs 28%, P<.001), and die while undergoing TB treatment (44% vs 14%, P<.001), and were less likely to have a positive tuberculin skin test (TST) (28% vs 44%, P<.001) and have TB care provided by a health department (20% vs 59%, P<.001). In multivariable analysis, NH residents who had a positive TST were less likely to die while undergoing TB treatment (odds ratio=0.39, 95% CI=0.16-0.96). TB incidence rates were lower, and reductions in incidence were greater among NH residents; community-dwelling older adults had higher TB rates and smaller reductions in incidence. Interventions that promote timely detection and treatment of TB infection and disease may be needed to reduce morbidity and mortality among NH residents.